435202301-1-19-2023-26-AS-KHOS-CNDRNN-20230124121039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202301
Report Date: 01/19/2023
Date Signed: 01/19/2023 03:19:27 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20230111110528

FACILITY NAME:	PALM VILLAS, CAMPBELL		FACILITY NUMBER:	435202301
ADMINISTRATOR:	SNEPER, GARRY		FACILITY TYPE:	740
ADDRESS:	3333 SOUTH BASCOM AVENUE		TELEPHONE:	(408) 559-8301
CITY:	CAMPBELL	STATE: CA	ZIP CODE:	95008
CAPACITY:	48	CENSUS: 45	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Blythe Obien		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff restricted visitation for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint investigation regarding the above allegation. LPA met with facility Resident Services Director Blythe Obien (S1).

LPA interviewed S1. When LPA asked S1 whether or not they had restricted visitation in any way, S1 stated that they had. S1 stated that during the christmas break, due to the rise in COVID numbers throughout the area, the facility had temporarily suspended visitation with exception for essential visits and visitation for hospice residents. S1 was contacted by an outside agency, who informed them that visitation had to be allowed. S1 stated that the facility lifted the visitation restriction when contacted by this agency.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20230111110528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PALM VILLAS, CAMPBELL	FACILITY NUMBER: 435202301
	VISIT DATE: 01/19/2023

NARRATIVE

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LPA asked S1 if they were allowing visitation within resident rooms at the facility. S1stated that visitation is largely restricted to the outdoor visitation area in the courtyard and the indoor visitation area located next to the facility office. LPA informed S1 that visitation shall not be restricted in any capacity, and that family members shall be permitted to visit loved ones within resident room and facility common areas.

Deficiency cited, see 9099-D. Appeal rights were provided. Administrator Garry Sneper was currently out of the country and was unable to be contacted during the investigation. LPA and S1 contacted temporary administrative authority Nora Saavera and a copy of the signed report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230111110528

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PALM VILLAS, CAMPBELL	FACILITY NUMBER: 435202301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/26/2023 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1(a)(11) - Personal Rights of Residents in All Facilities - (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility has already reopened visitation to family members of residents. Facility to update family members via email of lifting of visitation restrictions and CC LPA in the email.
	8 9 10 11 12 13 14	Based on interviews and records review, the facility restricted visitation from 12/21/2022 to 12/28/2023 for family members of residents. This presented a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

LIC9099 (FAS) - (06/04)

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